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Pain Perception and Management

Pain Exists whenever person says it does. Serves as an injury prevention mechanism. Highly individual.
Pain influenced by Affective: fatigue, Behavioral: age, cognitive, physiological sensory
Nociception Processing of painful stimuli
Transduction Impulses travel along afferent (sensory) nerve fibers
A-Delta Sharp, localized pain associated with injury
C-fibers Slow conducting, dull poorly localized pain after injury. First vs second.
Transmission Spinal Dorsal Horn- processing of message. Most important pathway for pain sensation.
Impulse Route A-delta & C-fibers in peripheral tissues -> dorsal route-> spinal dorsal horn -> spinothalmic tract -> brain stem -> thalamus
Neurotransmitters All cellular damage results in release of: prostaglandins, substance P, serotonin. Produce a pain-sensitizing inflammatory response.
Perception Personal awareness. Once the impulse reaches the cerebral cortex, the brain interprets the quality of pain based on past experiences, knowledge, and culture.
Modulation Inhibition of nocioceptive impulses in CNS. Once brain perceives pain, it releases endogenous opioids to produce analgesia: serotonin, norepinephrine.
Gate Control Theory Dorsal horn cells act as a gate: close to prevent nociceptive impulses from reaching the brain. A-delta & C-fibers open the "gate". Alpha and beta fibers close the gate.
Significance of the Gate Theory Provides ideas for pain relief emphasizing multiple dimensions of pain: sensory, emotional, behavioral, cognitive. Different pain relief interventions may be used to address various dimensions of pain for a more holistic approach to therapy.
Types of pain Acute-follows nociceptive pain process, persistent (chronic)- no useful purpose, cancer-first symptom to seek tx, nociceptive- somatic, visceral, neuropathic- nerve damage
Acute Pain Occurs abruptly with injury or disease. Lasts less than 6 months. May be associated with anxiety and fear. Typically increases with wound care, ambulation, coughing, deep breathing.
Chronic pain Lasts for prolonged period of time. Typically greater than 6 months. Associated with prolonged tissue pathology. May be associated with depression, frustration, or fear. Cause may be unidentifiable: Idiopathic.
Malignant pain Progressive pattern of recurrent, acute pain or persistent chronic pain. Resistant to treatment or cure. Intractable. Interferes with quality of life. May be described as all-consuming.
Lifespan considerations Newborn/infant- under treatment of pain. Toddler/preschooler- cannot ID pain. Schoolage/adolescent- can rationalize pain. Adult/older adult- MS pain. Cultural- communication/devalued.
Verbal Pain Subjective, most dependable indicator of pain, suffering.
Nonverbal Pain Gives clues to location of pain: rubbing, frowning, grimacing, guarding, immobilization, increase muscle tension.
Behavioral and Cognitive Factors Usual activities, anxiety, fear, aggression, physical withdrawal from activities, meaning associated with disease, cultural belief.
Manifestations of pain Increase BP, HR, resp.
Metabolic changes of pain Increase metabolism, O2 consumption, blood glucose, free fatty acids, blood lactate, ketones.
Pain Assessment Onset, duration, location, intensity, quality, pattern, relief
When to assess pain At regular intervals throughout treatment, with each report of pain, before and after nonpharmacologic treatment and medication administration.
Pain Onset Day and time that pain began. Any precipitating factors associated with pain onset.
Pain duration Temporal patterns: brief, momentary, transient, rhythmic, periodic, intermittent, continuous, steady, constant, breakthrough
Pain location May be measured objectively. Ask client to mark areas of pain- different symbols may indicate various types of pain and intensity. Ask client to point directly at area of pain. May be referred pain from another area.
Pain Intensity Typically measured on a scale of 0-10. Varies depending on: personal experience, personal expectations, ability to be distracted, level of consciousness, activity level
Pain threshold Amount of pain stimulation a person requires before feeling it.
Pain tolerance highest intensity of pain that person is willing to tolerate.
Pain quality How the pain is felt by a client: stabbing, crushing, burning, sharp, shooting, throbbing
Addiction A psychological state in which an individual seeks medications for purposes other than the prescribed purpose
Dependence A physiologic response of clients who take opioids regularly for greater than 10 days. Abrupt discontinuation elicits withdrawal symptoms.
Withdrawal Symptoms Anxiety, Nervousness, Irritability, increase salivation, increase perspiration, diarrhea, chills, hot flashes, nausea and vomiting, abdominal cramps
Tolerance Develops when a dose of opioid becomes less effective on repeated administration. Tolerance is not addiction. Involves physiologic changes r/t drug metabolism, nervous system's adaption to the med.
Need for increasing drug dosage may indicate Disease progression, new pathology.
Titration Adjusting drug dosage to clients response, balance of desired and adverse effects to maintain client comfort.
Tolerance Treatment Change to a different drug in the same classification. Add an adjuvant analgesic. May require increased doses of med.
Pain relief Non-Pharmacologic Relaxation, guided imagery, deep breathing, distraction, biofeedback, meditation, positioning, hygiene, cutaneous stimulation: massage, heat, cold, acupressure
Pharmacologic Management for Pain relief: Nonopioids Acetylsalicylic acid (ASA): analgesic, antipyretic, anti-inflammatory: decrease platelet aggregation.
Pharmacologic Management for Pain relief: NSAIDS Analgesic, antipyretic, anti-inflammatory
Adjuvant Analgesics Tricyclic antidepressants, antihistamines, caffeine, muscle relaxants, anticonvulants, antiemetic
Opioid agonists Morphine, codeine, hydromorphone, oxycodone, meperidine, fentanyl, methadone.
Opioid antagonist Narcan
Common side effects of opioids Constipation, nausea and vomiting, sedation, dizziness, pruritus, headache, dry mouth.
More serious side effects of opioids Resp depression, apnea, resp arrest, circulatory depression, hypotension, shock
Invasive Pain Management Intraspinal- Epidural/Intrathecal Used to control postop pain, chronic non-malignant pain, severe cancer pain. May be placed in the cervical, thoracic, lumbar, or caudal spinal regions.
Principles of Nonpharmacologic Pain Management Basic comfort measures-environment. Cutaneous stimulation-interrupts pain signal. Heat-vasodilation. Cold-vasoconstriction. Massage-tactile stimulation.
Pain evaluation/Documentation Ongoing assessment- character of client's pain. Client's response to interventions: nonpharmacologic, pharmacologic. Clients perception of pain relief measure effectiveness.
Created by: senmark
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